Access Inc.
416 Nancy Court *
Lawrence, Kansas 66049-4601 *
Voice: 785-841-0321 *
Fax: 785-841-1979
Name ____________________________________________________
Address _________________________________________________
City ____________________________________________________
State ________ Zip ______________________________________
Daytime Phone (____) ____________________________________
FAX Number (____) _______________________________________
Email Address ________________@__________________________
| Description | Quantity | Price Each | Total |
|---|---|---|---|
| ADA Accessibility Stick II | $39.95 |
Total Price of Items Ordered:______________________________
Shipping and Handling
add $7.00 for each item: __________________________________
Kansas residents only,
add 6.9% state sales tax: _________________________________
Total Order Amount:________________________________________
(call or write for bulk rate)
Method of Payment: __ MasterCard __ Visa
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Card Number
__ __ __ __
Expiration Date
_______________________________________________
Cardholder's Signature
__ Check __ Purchase Order Number ________________________________
Please print this order form and send with your payment to Access Inc.
Payments cannot be accepted over the internet at this time.
Thank you for your order.
Your business is very much appreciated!